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Form 8283 (Rev, 10-95)
<br />
<br />Name(s) shown on your income tax return
<br />
<br />EXHIBIT B1
<br />
<br /> Pa~e 2
<br /> IIdenl~fying number
<br /> 476-18-9714
<br />
<br /> Wilfred D. & Katherine A. Gagne
<br />Section B--Appraisal Summary--List in this section only items (or groups of similar items) for which you claimed a
<br /> deduction of more than $5,000 per item or group. Exception. Report contributions of certain publicly
<br /> traded securities only in Section A.
<br /> If you donated art, you may have to attach the complete appraisal. See the Note in Part I below.
<br />
<br />I:,~'Till Information on Donated Property--To be corr, pleted by the taxpayer and/or appraiser.
<br /> 4 Check type of property:
<br /> [] Art' (contribution of $20,000 or more) [] Real Estate [] Gems/Jewelry [] Stamp Collections
<br /> [] Art' (contribution of less than $20,000) [] Coin Collections [] Books [] Other
<br />'Art includes paintings, sculptures, watercolors, pdnts, drawings, ceramics, antique fumiture, decorative arts, textiles, carpels, silver, rare
<br />manuscripts, historical memorabilia, and other similar objects.
<br />Note: If your total art contribution deduction was $20.000 or more. you must attach a complete copy of the signed appraisal. See instructions,
<br />
<br />A
<br />B
<br />
<br />(a) Description of donated property (if you need
<br /> more space, attach a separate statement)
<br />
<br />(d) Date acquired
<br />by donor {mo,, yr.)
<br />
<br />(b) If tangible property was donated, give a brief summary of the overall
<br /> physical condition at the time of the gift
<br />
<br />(c) Appraised fair
<br />market value
<br />
<br />L
<br />
<br />(e) How acquired
<br />by donor
<br />
<br />Donor's cost or (g) For bargain sales, enter
<br />adjusted basis amount received
<br />
<br /> See instructions
<br />Amount claimed (i) Average trading price
<br /> deduction of securities
<br />
<br /> Taxpayer (Donor) Statement--List each item included in Part above that is separately identified in thu
<br /> appraisal as havinq a value of ;500 or less. See instructions.
<br />I declare that the following item(s) included in Part I above has to the best of my knowledge and belief an appraised value of not more than $500
<br />~oer item). Enter identifying letter from Part I and describe the specific item. See instructions. IF
<br />
<br />Signature of taxpayer (donor) IF Date IF
<br />
<br />IU~'llllll Declaration of Appraiser
<br />I declare that I am not the donor, the donee, a party to the transaction in which the donor acquired the property, employed by, or related to any
<br />of the foregoing persons, or married to any person who is related to any of the foregoing persons. And, if regularly used by the donor, donee, or
<br />party to the transaction, I performed the majodty of my appraisals dudng my tax year for other persons.
<br />Also, I duclare that I hold myself out to the public as an appraiser or perform appraisals on a regular basis; and that because of my qualifications
<br />as described in the appraisal, I am qualified to make appraisals of the type of property being valued. I certify that the appraisal fees were not based
<br />on a percentage of the appraised property value. Furthermore, I understand that a false or fraudulent overstatement of the property value as
<br />described in the qualified appraisal or this appraisal summary may subject me to the penalty under section 6701(a) (aiding and abetting the
<br />understatement of tax liability). I affirm that I have not been barred from presenting evidence or testimony by the Director of Practice.
<br />
<br />Here Tit, e IF / Date of appraisal IF
<br />Bus'ness~__///~.~&add ss (' (J,'/~--~ .ro. gj[~.__~L~ , cb~/'p°.)'' ,1
<br />City or town, state, and.~lP code . , ~-
<br />
<br />It~'Ta.P~ Dorme Acknowled{lment--To be completed by the charitable organization.
<br />This charitable organization acknowledges that it is a qualified organization under section 170(c) and that it received the donated
<br />property as described in Section B, Part 1, above on ·
<br /> (Date)
<br />
<br />Furthermore, this organization affirms that in the event it sells, exchanges, or otherwise disposes of the proper[), described in Section
<br />B, Part I (or any portion thereof) within 2 years after the date of receipt, it will file Form 8ZSZ, Donee Information Return, with the
<br />IRS and give the donor a copy of that form, This acknowledgment does not represent agreement with the claimed fair market value.
<br />
<br />Name of chantable organization (donee) Employer identification number
<br />,ddress (number, street, and room or suite no.) City or town, state, and ZIP code
<br />
<br />Authorized signature
<br />
<br />Title I Date
<br />
<br /> Pfned
<br /> on recycled paper
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